Purpose
The purpose of the Intermediate Care accelerator project is to undertake a review of the Community Recovery Service CRS - (an integrated service of health and social care offering short term reablement and rehabilitation). This service is a significant component of Hounslow’s Intermediate Care offer (home based rehabilitation, reablement, and non-urgent based admission avoidance and discharge support). The ambition of this project is to:
- Improve the Intermediate Care offer in Hounslow so that there is good community step-up provision (preventing avoidable unplanned hospital admissions and transfers to residential care)
- Optimise pathways by focussing our CRS’ expertise on patients to whom we can make a material difference to their wellbeing and rehabilitation.
The overarching objectives of this project are to contribute to reducing avoidable hospital admissions and placements into residential care, and increasing independence among residents aged 65 plus who have been supported by the service.
- Complete evaluation of the Rehab Nurses pilot (Oct 2023-Oct 2025) – due Feb 2026
- Complete evaluation of the Let's Go Outside and Learn pilot (Jan 2024-Jan 2026) – due April 2026
- Develop community medication policy specifically for the Reablement service – work in progress (Q3-Q4 2025/26)
- Adopt recommendations from the NHSE Intermediate Care workforce pilot, where Hounslow was one of 6 test and learn sites (ongoing)
- A refreshed integrated criteria for CRS was agreed in September 2023 – this will help referrers identify patients suitable for reablement and/or rehabilitation in a single criteria. This has been in use since then, and will be reviewed periodically to ensure it is achieving a more appropriate flow into the service.
Earlier project delivery phases included: research and stakeholder engagement which can be evidenced via the following case studies: